An Integrative Approach to Pain Management

Audra Fox, MD
OU Dept of Family Medicine
2012 Pain Summit
05 October 2012
Why do we need to discuss pain management
options
 Introduce CAM / Integrative Medicine
 Define commonly misunderstood terms
 Discuss briefly the 5 domains as defined by the
NIH
 Discuss at least one alternative option for pain
management
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I have no financial disclosures or conflicts of interests.
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Time off work
$$$
Addiction / Recovery
Physician Liability
Oklahoma specifically
Does it work – pt satisfaction
Condition
Number of Suffers
Source
Chronic Pain
100 million Americans
Institute of Medicine of
The National Academies
Diabetes
25.8 million Americans
American Diabetic
Association
(diagnosed and estimated undiagnosed)
Coronary Heart Disease
16.3 million Americans
American Heart
Association
Stroke
7.0 million Americans
American Heart
Association
Cancer
11.9 million Americans
American Cancer society
(Heart attack and chest pain)
www.painmed.org
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American Pain Foundation
 evaluated the impact that chronic pain had on 303 chronic pain sufferers who
sought care from their physician and were currently using an opioid to treat
their pain
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Control Over Chronic Pain
 More than half of respondents (51%) felt they had little or no control over
their pain.
 Six out of ten patients (60%) said they experience breakthrough pain one or
more times daily, severely impacting their quality of life and overall wellbeing.
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Impact on Quality of Life
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Almost two-thirds (59%) reported an impact on their overall enjoyment of life.
More than three quarters of patients (77%) reported feeling depressed.
70% said they have trouble concentrating.
74% said their energy level is impacted by their pain.
86% reported an inability to sleep well.
The total annual incremental cost of health
care due to pain ranges from
$560 billion to $635 billion
(in 2010 dollars) in the United States, which
combines the medical costs of pain care and
the economic costs related to disability days
and lost wages and productivity
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The number of prescriptions filled for opioid pain
relievers has increased dramatically in recent
years.
 From 1997 to 2007, the milligram-per-person use of
prescription opioids in the U.S. increased from 74
milligrams to 369 milligrams, an increase of 402%.
 In addition, in 2000, retail pharmacies dispensed 174
million prescriptions for opiods; by 2009, 257 million
prescriptions were dispensed, an increase of 48%
www.whitehouse.gov/ondcp
#1 in the country – recreational painkiller use
Approximately 240,000 Oklahomans (8% of the
population) age 12 and above took prescription
painkillers for nonmedical reasons over a 12month period
 On an average day, 2 Okies die from drug
overdoses.
 More deaths from drug overdoses than MVA
 On any given day, 600-900 are waiting on bed in
a publicly funded residential substance abuse
center.
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$5.4 billion on indirect cost
 Absenteeism and reduced productivity
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$1.8 billion on direct cost
 Hospital, doctors, police, prisons
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Total: $7.2 billion
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In 1999, the NIH established
the National Center for
Complementary and
Alternative Medicine
(NCCAM)
 >800 studies funded at >130
institutions
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CAM use is Increasing
 40-60% Americans use CAM
each year
 Overwhelming majority seek
care from their physician
BEFORE they see an alternative
provider
Eisenberg DM et al Ann Intern Med 2001;135:344
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Conventional / Western / Allopathic medicine
 practiced by holders of M.D. and D.O. degrees and by allied
health professionals, such as physical therapists,
psychologists, and registered nurses
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CAM – complementary and alternative
 “Healing philosophies, approaches, therapies that
mainstream Western medicine does not commonly use,
accept, study, understand or make available”
Complementary - the use of CAM together with
conventional medicine
 Alternative - use of CAM in place of conventional
medicine
 Integrative - a practice that combines both
conventional and CAM treatments for which there is
evidence of safety and effectiveness
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Types of CAM Used by Americans Age ≥50
AARP/NCCAM Survey
Massage, chiropractic or other
bodywork
Herbal products or dietary
supplements
Mind-body practices: hypnosis,
meditation, etc.
45%
$33.9
42%
15%
Naturopathy, acupuncture, or
homeopathy
14%
BILLION
Energy therapies, including
magnets and Reiki
10%
2%
Other
0%
10%
20%
30%
40%
50%
1.
2.
3.
4.
5.
Biologically based
Manipulative & Body-based
Energy Medicine
Mind-Body Medicine
“Whole Medical Systems”
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Dietary supplements
Botanicals / Herbal products
Probiotics
Derived from the
leaves of the plant
 Used primarily to treat
migraine headaches
 Recently, Aveeno
skincare brand added
feverfew to its Active
Naturals line
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 to calm red and irritated
skin.
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170 pts with migraine
Randomized to receive 6.25 mg feverfew CO2-extract or
placebo three times a day for 16 weeks
Results showed that the frequency of migraines
decreased by 1.9 attacks in the treatment group and by
1.3 attacks in those on placebo from 4.79 attacks per
month.
Difference was found to be statistically significant.
The feverfew extract was well tolerated with nonspecific
adverse effects that were seen in the placebo group as
well.
Researchers conclude that feverfew is effective in
reducing the frequency of migraine attacks in patients.
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Some laboratory tests show that feverfew
can reduce inflammation
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One study found that feverfew was no better
than placebo in improving rheumatoid
arthritis symptoms
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To prevent or stop a migraine:
 Take 100 - 300 mg, up to 4 times daily, standardized to contain 0.2 -
0.4% parthenolides
 supplements that are carbon dioxide extracted - take 6.25 mg, 3 times
daily, for up to 16 weeks
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Rheumatoid arthritis:
 120 - 60 drops, 2 times daily of a 1:1 w/v fluid extract
 60 - 120 drops 2 times daily of 1:5 w/v tincture.
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Side Effects:
 Minor gastrointestinal distress.
 Oral ulcerations may result from chewing fresh feverfew leaves.
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Precautions:
 Feverfew may increase the risk of bleeding, especially if you take
blood-thinning medications such as warfarin (Coumadin) or aspirin
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Capsaicin is believed to cause depolarization of C-fiber
polymodal nociceptors thereby releasing substance P,
which is a neurotransmitter that relays pain signals to
the brain.
 The sensation of pain actually increases upon application
of capsaicin due to release of substance P, but subsides
when its levels are depleted at the afferent neurons
Effective use of capsaicin requires topical application
4 or 5 times daily for a period of at least 4 weeks
 Uses: Arthritis, diabetic neuropathy, shingles, cluster
HA
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8-week double-blind, multicenter, parallel study with 235
pts
Compared the safety and efficacy of topical capsaicin and
oral amitriptyline in patients with painful diabetic
neuropathy involving the feet.
A visual analogue scale of pain intensity and
measurements of interference by pain with functional
activities were recorded at onset and at 2-week intervals.
Topical capsaicin and oral amitriptyline produced equal
and statistically significant improvements in pain over
the course of the study.
By the end of week 8, 76% of patients in each group
experienced less pain, with a mean reduction in intensity
of more than 40%.
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No systemic side effects were observed in
patients treated with topical capsaicin. Most
patients receiving amitriptyline experienced at
least one systemic side effect, ranging from
somnolence (46%) to neuromuscular (23%) and
cardiovascular (9%) adverse effects.
Topically applied capsaicin is an equally
effective but considerably safer alternative to
amitriptyline for relief of the pain of diabetic
neuropathy.
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Topical: 0.025%-0.075% capsaicin creams
may be applied three to four times a day and
have a duration of action of about 4-6 hours.
If applied with fingers, wash hands
afterwards with a diluted vinegar solution.
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Connective tissue health and formation of
collagen
USES: Arthritis, cramps
Dosage: 2-10 grams
SE: No toxic effect shown in humans
Oregon Health Science University
 animals that were given MSM showed no
degeneration of cartilage associated with RA
Alpha-lipoic acid acts as a lipophilic free radical
scavenger
 Can assist in repairing oxidative damage and
regenerate endogenous antioxidants such as
vitamin C, vitamin E, and glutathione.
 DHLA and lipoic acid also have metal chelating
capacities.
 Essential cofactor in the production of energy
and acts as a potent antioxidant and exerts
apoptotic effects on tumor cell lines .
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In human studies, alpha-lipoic acid improved
insulin sensitivity, vasodilation, and
polyneuropathy in patients with diabetes
mellitus
A meta-analysis of clinical trials of alphalipoic acid in diabetic patients showed a
significant reduction in neuropathic
symptoms
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A meta-analysis of clinical trials of alpha-lipoic acid and
symptomatic polyneuropathy.
Four trials met the stringent inclusion criteria (randomized,
double-blind, placebo, using 600 mg i.v. per day for three weeks,
except for weekends, in diabetic patients with positive sensory
symptoms of polyneuropathy scored by the Total System Score in
the feet on a daily basis).
The analysis included 1258 patients following an intention-totreat principle.
Improvement was first noted after eight days of treatment.
After three weeks, responder rates for patients receiving alphalipoic acid was 53% versus 37% for placebo.
The difference was statistically significant.
Researchers suggest that alpha-lipoic acid may be clinically
meaningful as a treatment for diabetic polyneuropathy.
Dose: 300 mg BID
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Spinal manipulation
Massage therapy
“Movement Therapies”
 Feldenkrais method
 Alexander technique
 Pilates
 Rolfing Structural Integration
 Trager psychophysical integration
 Strain CounterStrain
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A 2008 review of 13 clinical trials found evidence
that massage might be useful for chronic lowback pain
A multisite study of more than 300 hospice
patients with advanced cancer concluded that
massage may help to relieve pain and improve
mood for these patients.
Prospective randomized trial, participants
received 8 weeks of Swedish massage therapy
showed significant improvement in pain,
stiffness, and physical function. These
improvements persisted to 16-week evaluation.
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Airrosti
 Applied Integration for the Rapid Recovery of Soft
Tissue Injuries
 No / Limited Studies
 Post treatment survey
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Total Number of Patient Cases in 2011: 33,152
Average Treatment Duration: 2.9 Visits
 99.7% of patients reported they would recommend
Airrosti to friends and family.
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Did Airrosti Resolve Your Injury/Condition?
 88.4%
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Did Airrosti Help Prevent a Recommended Surgery?
 1,104
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Did Airrosti Help Reduce/Eliminate the Need for
Meds?
 93%
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Did Airrosti Prevent Further Medical Services?
 91%
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Magnet therapy
Light therapy
Qi gong
Reiki
Healing touch
Ki Iki Jutsu
Acupuncture
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Scientific evidence does not support the use
of magnets for pain relief.
Magnets may not be safe for some people,
such as those who use pacemakers or insulin
pumps, as magnets may interfere with the
devices.
Otherwise, magnets are generally considered
safe when applied to the skin.
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Gentle touch assists in balancing your physical,
mental, emotional, and spiritual well-being.
The provider will ask a series of questions about
the individual’s physical, mental, and emotional
situation, and will answer any questions. Then
the individual will lie fully clothed on a massage
table while the provider gently places their
hands slightly above or on the individual. The
session generally lasts 40 to 60 minutes, and
people frequently report feeling deeply relaxed
and peaceful during and after the session.
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Several, small studies
Focuses include: post-op healing and pain,
muscle pain and spasms, depression, anxiety,
abuse in women.
One year study of 30 pts with End-Stage Liver
Disease showed statistically significant
improvement in pain and anxiety.
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Holistic Approach to Treatment of Intractable
Central Neuropathic Itch
 25 yo male who sustained a TBI
 “hundreds of mosquitoes biting me”
 Received 10 sessions of conventional high dose
and aggressive pharmacotherapy and
psychotherapy – 10/10
 Bi-weekly HT for 1 month – 2/10
 After 4 months of sessions, itch free.
Low frequency sound waves used (7.83-13.5 Hz) over
area of pain or injury.
 T.E.N.S : A study carried out concluded that for
patients with chronic low back pain, treatment with
TENS is no more effective than treatment with a
placebo, and TENS adds no apparent benefit to that
of exercise alone. (N Engl J Med 1990; 322: 1627–34.)
 2009 Cochrane systemic review of TENS for knee OA
concluded that available studies were too small and
poorly designed to judge its effectiveness. However,
its use in tibiofemoral OA has yielded good results.
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The effect of foot reflexology on pain in pts with
metastatic cancer:
 36 oncology inpatients
 Foot reflexology was found to have a positive
immediate effect for patients with metastatic
cancer who report pain
 no statistically significant effect at 3 hours after
intervention or at 24 hours after intervention.
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Further study is suggested for foot reflexology
delivered by family in the home for
management of cancer pain.
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Meditation
Yoga
Deep-breathing exercises
Guided Imagery
Hypnotherapy
Progressive Relaxation
Qi gong
Tai Chi
Tai Chi is a traditional style of Chinese martial arts that
features slow, rhythmic movements to induce mental
relaxation and enhance balance, strength, flexibility,
and self-efficacy.
 Researchers from Tufts University School of Medicine:
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 Patients over 65 years of age with knee osteoarthritis (OA)
who engage in regular Tai Chi exercise improve physical
function and experience less pain.
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In a long-term study comparing Tai Chi with regular
exercise in patients with symptomatic OA of the knee,
researchers found that those in the Tai Chi group
showed greater improvement in pain, physical
function, self-efficacy, depression, and healthrelated quality of life, with some improvements
lasting as long as 48 weeks.
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The sixth most commonly used
complementary practice among adults
Randomized Trial at conducted by York
University in the U.K for Yoga for chronic low
back pain.
 313 adults
 12-week yoga program led to greater
improvements in back function than did usual
care.
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Naturopathy
Homeopathy
TCM - Traditional Chinese Medicine
Ayurveda
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Belladonna: Throbbing HA
Kali Biochromicum: Sinus HA
Nux Vomica :Tension HA with N&V
Rhus toxicodendron (Poison Oak) reduced
tender points by 25% in patients with
fibromyalglia following 4 weeks of
treatment.
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Experimental studies on the effects of arnica
preparations have demonstrated
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Antimicrobial
anti-inflammatory
respiratory-stimulant
positive inotropic
tonus increasing actions
Clinical trials conducted suggest benefits of
arnica for osteoarthritis and reduction in
postoperative swelling and pain
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Randomized, double-blind, controlled, multicenter study
204 outpatients with osteoarthritis of the interpharyngeal
joints.
Patients were randomized to receive 5% topical ibuprofen or
arnica gel 3 times daily for 3 weeks.
Patients were also allocated a preset number of acetaminophen
tablets to be used as a “rescue treatment” if the pain was
unbearable.
Study results indicated that the arnica gel was comparable to
ibuprofen gel with respect to hand functional capacity, pain
intensity, number of painful joints, duration and severity of
morning stiffness, and acetaminophen consumption.
The researchers concluded that arnica gel can be used as an
alternative to ibuprofen gel in patients with osteoarthritis of
the hand.
Bruise reduction: Arnica ointment 20%, under
occlusion, bid for two weeks
 Osteoarthritis: A 4 cm strip of arnica gel rubbed
on affected joints TID for 3 weeks
 Internal use of arnica is not advised. The effects
of arnica on the lungs, heart, and uterus have
not been sufficiently tested to justify the risks
associated with oral use. A fatal case of
poisoning has been reported following ingestion
of 70 g of arnica tincture. The FDA considers oral
Arnica an unsafe herb. External use appears to
pose no risk.
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Acupuncture
 aims to restore and maintain
health through the stimulation
of specific points on the body.
 Studies / Research – lots!
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Mummified body found along border of
Austria & Italy – dated 3000 BC
 Had tattoo markings that correspond to current
acu-points
 X-rays revealed arthritis
of the lumbar spine
 9 out of 15 pts
“Rapid Cancer Pain Relief with Auricular
Micro-Macro Technique”
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One of the worlds oldest medical systems
Originated in India
Recruiting participants with Breast Cancer at
University of California, San Francisco
 Integrative Approaches to Cancer Survivorship
 Primary Outcome Measures: Change in the
quality of life over 16 weeks with ayurvedic
intervention.
107 patients with primary knee osteoarthritis
Randomized to receive 800 mg/day ibuprofen or 2g/day C.
domestica extracts for 6 weeks.
 Improvement in pain on level walking, pain on stairs, and
functions of the knee assessed by time spent during a 100-m walk
and going up and down a flight of stairs were the primary outcome
measures.
 The authors reported significant improvement at 0, 2, 4 and 6
weeks compared with baseline values in both groups, with the
exception of pain on stairs (p = 0.016). Adverse events also did not
differ much between the groups (33.3% vs 44.2%, p = 0.36 with C.
domestica extracts and ibuprofen).
 C.domestica extracts demonstrated efficacy and were safe
compared with ibuprofen in the treatment of knee
osteoarthritis
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Dosing:
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Cut root: 1.5 - 3 g per day
Dried, powdered root: 1 - 3 g per day
Standardized powder (curcumin): 400 - 600 mg, 3 times per day
Fluid extract (1:1) 30 - 90 drops a day
Tincture (1:2): 15 - 30 drops, 4 times per day
Precautions:
 taking large amounts of turmeric for long periods of time may cause
stomach upset and, in extreme cases, ulcers.
 People who have gallstones or obstruction of the bile passages should
talk to their doctor (couldn’t find an explanation)
 Turmeric may lower blood sugar levels, so be careful in DM pts
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CAM – complementary and alternative
 “Healing philosophies, approaches, therapies that
mainstream Western medicine does not
commonly use, accept, study, understand or
make available”
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Integrative - a practice that combines both
conventional and CAM treatments for which
there is evidence of safety and effectiveness
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Survey in 2007, 40 % used at least one form of
CAM for their pain.
Current Research
 CAM therapies for chronic low-back pain, including
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acupuncture, massage, spinal manipulation, and yoga
CAM therapies for osteoarthritis pain, including
prolotherapy, tai chi, and yoga
Massage for chronic neck pain
Acupuncture and spinal manipulation for
chronic headaches
Acupuncture and tai chi for fibromyalgia pain.
Low-Back Pain
Promising Evidence of
Potential Benefit
Acupuncture
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Massage
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Spinal Manipulation
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Progressive
Relaxation
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Yoga
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Limited, Mixed, or No
Evidence To Support Use
Prolotherapy
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Herbal Remedies
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Promising Evidence of
Potential Benefit
Acupuncture
Limited, Mixed, or No
Evidence To Support Use
√
Glucosamine/
Chondroitin
√
Gamma Linolenic Acid
(GLA)
√
Herbal Remedies
√
Balneotherapy
(Mineral Baths)
√
Tai Chi
√
Promising Evidence of
Potential Benefit
Acupuncture
√
Spinal Manipulation
√
Feverfew
Limited, Mixed, or No
Evidence To Support Use
√
Neck Pain
Promising Evidence of
Potential Benefit
Limited, Mixed, or No
Evidence To Support Use
Acupuncture
√
Spinal Manipulation
√
Questions?
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http://www.mskcc.org/cancercare/herb/alpha-lipoic-acid
http://www.mskcc.org/cancercare/herb/turmeric
http://www.ncbi.nlm.nih.gov/pubmed/196787
80
http://www.mskcc.org/cancercare/herb/feverfew
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http://www.ncbi.nlm.nih.gov/pubmed/162321
54
http://www.ncbi.nlm.nih.gov/pubmed/101503
23
http://www.nejm.org/doi/full/10.1056/NEJM1
99006073222303
http://www.ncbi.nlm.nih.gov/pubmed/14608
562
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http://www.sciencedaily.com/releases/2009/10/0
91029102417.htm
http://www.ncbi.nlm.nih.gov/pubmed/22041945
http://www.ncbi.nlm.nih.gov/pubmed/18607237
http://www.ncbi.nlm.nih.gov/pubmed/15261979
Harris, et. Chronic Pain Perspectives: A
supplement to the Journal of Family Practice.
September 2011. Vol 60, No 9.